Implications of cardiovascular technology diffusion among Medicare beneficiaries

描述（由申请人提供）：最近食品和药物管理局批准了药物洗脱冠状动脉支架（2003年）和颈动脉支架（2004年），以及医疗保险和医疗补助服务中心（CMS）扩大了植入式心律转复除颤器的覆盖适应症（2003年和2005年），使数十万老年医疗保险受益人成为昂贵心血管技术的新合格接受者。这些监管决定导致政府每年在老年人心血管保健方面额外支出数十亿美元。由于新技术是医疗保健成本的主要驱动因素，政策制定者一直试图塑造新技术向医疗保健市场扩散的过程。医疗保险新推出的“循证覆盖”政策，以及将某些技术的覆盖范围限制在“高质量”的医院，就是这样的两个例子。然而，在确保医疗保健技术的有效使用（以最小的成本最大化健康结果）和促进医疗保健公平（为历史上处于不利地位的医疗保险受益人提供同等的机会获得有前途的技术）之间存在固有的紧张关系。为了探索这种紧张关系的两端，我们将分析2001-2006年国家医疗保险索赔数据，以追求以下目标：(1)我们将描述美国医院和小地理区域在早期采用药物洗脱冠状动脉支架、用于心源性猝死一级预防的植入式心律转复除颤器和颈动脉支架模式方面的差异，并确定这种差异是否与CMS管理技术覆盖范围的政策差异、技术采用的财政激励、医院的结构/财务特征、以及当地卫生系统的特点。(2)我们将确定早期采用这些技术的差异是否对这些疗法在医院或具有大量种族和少数民族和/或社会经济地位低人口的小地理区域的可获得性产生重大影响。(3)与那些被确定为缓慢或持续低采用者的医院和地方相比，我们将估计在技术推广的头几年里，被确定为早期采用者的医院和地方的临床结果的改善和成本的增加。与公共卫生的相关性：有效但昂贵的新型心血管设备不断且频繁地进入医疗市场。因此，无论种族、地点或卫生系统特征如何，公众都对优化使所有美国老年人都能使用有益的新技术的过程，以及促进系统范围内有效采用这些新技术，使这些疗法最大限度地为所有临床适宜的受益者提供健康益处的机会，同时最大限度地减少对日益有限的卫生保健资源的使用，都有浓厚的兴趣。

DESCRIPTION (provided by applicant): Recent Food and Drug Administration approvals of drug-eluting coronary stents (2003) and carotid arterial stents (2004), as well as the expansions of coverage indications for implantable cardioverter- defibrillators (2003 and 2005) by the Centers for Medicare and Medicaid Services (CMS), have made hundreds of thousands of elderly Medicare beneficiaries newly eligible recipients of expensive cardiovascular technologies. These regulatory decisions entail additional expenditures of billions of dollars annually by the government on cardiovascular health care for the elderly. As new technologies are the leading driver of health care costs, policymakers have been attemping to shape the process by which new technologies diffuse into the health care marketplace. Policies such as Medicare's new "Coverage with Evidence Determination," as well as limiting coverage of some technologies to hospitals that are "high quality," are two such examples. However, there is an inherent tension between ensuring that health care technologies are used efficiently (maximizing health outcomes at minimum cost), and promoting health care equity (providing equivalent access to promising technologies to historically disadvantaged Medicare beneficiaries). To explore both ends of this tension, we will analyze national Medicare claims data from 2001-2006 in pursuit of the following goals: (1) We will describe differences across U.S. hospitals and small geographic areas in the patterns of early adoption of drug-eluting coronary stents, implantable cardioverter- defibrillators for primary prevention of sudden cardiac death, and carotid arterial stents, and determine if this variation was associated with differences in CMS policies governing technology coverage, financial incentives for technology adoption, structural/financial characteristics of hospitals, and local health system characteristics. (2) We will determine if variation in early adoption of these technologies had significant impact on the availability of these therapies in hospitals or small geographic areas with large racial and ethnic minority and/or low socioeconomic status populations. (3) We will estimate improvements in clinical outcomes and concurrent increases in costs during the first years of technology diffusion in hospitals and localities identified as early adopters, compared to those identified as slow or persistently low adopters. Relevance to public health: An unending stream of effective-but-expensive new cardiovascular devices continually and frequently enters the medical marketplace. Thus, the public has strong interests in both optimizing the process by which beneficial new technologies become available to all elderly Americans regardless of their race, location, or health system characteristics, as well as promoting efficient system-wide adoption of these new technologies so that these therapies maximize the opportunity for health benefits for all clinically-appropriate beneficiaries while minimizing the use of increasingly limited health care resources.